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<title>Untitled Document</title>
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<body>
<div id="wrap_element">
    <div id="element_left" >
        <p style="position: relative;"><label>Effective Date</label><input type="text" id="datepicker"/><label for="datepicker" class="datepickerimg"><img src="images/datetime.png"/></label></p>
        <p><label>Well Name</label><input type="text"/></p>
        <div class="wrapselect" style="margin-top: -13px;">
          <label>Select a Run Number</label>
            <select class="select" title="Select one">
                <option>--Select a run number --</option>
                <option>Select a run number</option>
                <option>Select a run number </option>
            </select>
        </div>
        <div class="wrapselect">
            <label>Select an ATP</label>
            <select class="select" title="Select one">
            	 <option>--Select an ATP --</option>
                 <option>Select an ATP </option>
            </select>
        </div>
        <div class="wrapselect">
          <label>Select an PL</label>
            <select class="select" title="Select one">
                 <option>--Select an PL --</option>
            </select>
        </div>
        <div class="wrapselect">
        <label>Select a property</label>
            <select class="select" title="Select one">
          	     <option>--Select Property --</option>
            </select>
        </div>
        <div class="wrapselect">
          <label>Select a stimulation </label>
            <select class="select" title="Select one">
            	  <option>--Select stimulation --</option>
            </select>
        </div>
        <div class="wrapselect">
            <label>Select a stimulation </label>
            <select class="select" title="Select one">
            	  <option>--Select stimulation --</option>
            </select>
        </div>
    </div>
    <div id="element_right">
        <p>
            <label class="name">Scada</label>
            <input type="radio" name="scada" class="styled" id="sacada1"/>
            <label for="sacada1">Yes</label>
            <input type="radio" name="scada"  class="styled" id="sacada2"/>
            <label for="sacada2">No</label>
        </p>
        <p>
            <label class="name">Telemeted</label>
            <input type="radio" name="telemeted" class="styled"  id="telemeted"/>
            <label for="telemeted">Yes</label>
            <input type="radio" name="telemeted" class="styled"  id="telemeted1"/>
            <label for="telemeted1">No</label>
        </p>
        <p>
             <label class="name">Deleted</label>
            <input type="radio" name="deleted" class="styled" id="deleted"/>
            <label for="deleted">Yes</label>
            <input type="radio" name="deleted" class="styled" id="deleted1"/>
            <label for="deleted1">No</label>
        </p>
        <p>
             <label class="name">Active</label>
            <input type="radio" name="active" class="styled" id="active" />
            <label for="active">Yes</label>
            <input type="radio" name="active" class="styled" id="active1"/>
            <label for="active1">No</label>
        </p>
        <p>
             <label class="name">reported</label>
            <input type="radio" name="reported" class="styled" id="reported"/>
            <label for="reported">Yes</label>
            <input type="radio" name="reported" class="styled" id="reported1"/>
            <label for="reported1">No</label>
        </p>
        <p>
             <label class="name">ILUA Royalty Applicable</label>
            <input type="checkbox" name="ilua" class="styled"/>
            
        </p>
        <p>
             <label class="name">Top of Pump(mRT)</label>
            <input type="text" />
        
        </p>
        <p><label class="name">Pump Intake (mRT)</label><input type="text"/></p>
    </div>
</div>
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